PARTIAL KNEE MENISCECTOMIES LINKED TO OSTEOARTHRITIS

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PARTIAL KNEE MENISCECTOMIES LINKED TO
OSTEOARTHRITIS
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A meniscal tear is one of the most common
sports-related knee injuries in the United
States. Traumatic tears in young athletes and
middle-aged weekend warriors are usually treated
surgically, even though beneficial evidence from
clinical trials is lacking. Instead, research has
shown that total and partial-knee meniscectomies
are linked to early osteoarthritis. 6, 7, 34 Arth
roscopic partial meniscectomy Arthroscopic
partial meniscectomy is the most frequently
performed orthopedic surgery in the world.
Approximately 500,000 are performed each year in
the USA, 40 of whom are patients under 45 years
old. The concern is that long-term outcomes have
shown an increase in developing osteoarthritis
compared to non-surgical counterparts. Research
as far back as 1948 revealed that the removal of
the meniscus results in early osteoarthritis.
Eventhough the vitality of the meniscus was
well-known 80 years ago, surgeons still routinely
removed it. In the 80s and early 90s many young
adults found themselves requiring a full knee
replacement 20 years after knee surgery.
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Arthroscopic allowed a less-invasive procedure
and surgeons then changed to only partial removal
of the meniscus attempting to maintain as much as
they could. For years, arthroscopic knee surgery
was shown to have positive early and long-term
outcomes. But surgery was rarely compared to sham
surgery or conservative care/physical therapy.
Today, meniscus surgery aims to preserve as much
tissue as possible. Only recently has research
looked at the outcomes of partial meniscectomy to
sham surgery or conservative care/ physical
therapy. But compared to conservative care, the
risk of arthritis is still found more significant
in the surgical group. Knee Anatomy Causes of
Knee Pain   Meniscal Anatomy The meniscus is
fibrous cartilage or a cushion between the upper
femur and the lower tibia bone. It is divided
into three zones based on the degree of
vascularization. The thickest outer region, known
as the red zone is highly vascularized, while
the inner central region is very thin. Due to the
vascularization or blood supply, the red zone is
enriched in nutrients that enable self-healing.
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The inner (middle) region is referred to as the
red-white zone, which contains less
vascularization than the red-red zone and has
minimal self-healing capacity. The innermost
region of the meniscus is completely devoid of
blood supply and appears to lack the ability to
self-repair. Meniscus tears are a particular risk
for older athletes since the meniscus weakens
with age. More than 40 of people 65 or older
have them. The anterior horn of the medial
meniscus attaches near the anterior cruciate
ligament (ACL) on the tibia, whereas the
posterior horn attaches above the posterior
cruciate ligament (PCL). It is very common to
have a meniscal injury when the ACL or PCL
ligaments are torn. Knee Meniscal Injury The
most common injury to the knee is a tear in the
meniscus. Any activity that causes you to twist
or rotate your knee forcefully can lead to a tear
in the meniscus, especially when putting your
full weight on it. Sometimes, a piece of the
shredded cartilage breaks loose and catches in
the knee joint, causing it to lock up. The
meniscus performs vital functions of shock
absorption and provides mechanical stability and
lubrication to the knee joint. Unlike articular
cartilage or coverings on the outside of the
bones, the menisci are soft t and kept in place
by ligamentous attachments, allowing them to
slide during knee bending and straightening. 
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Shock absorption or protecting the knee from wear
and tear is the primary function of the meniscus.
When the meniscus is reduced due to surgical
resection, the load distribution is thrown off,
causing an increased force on the articular
cartilage during weight-bearing. This interferes
with shock absorption, which can lead to
breakdown and eventually leads to osteoarthritis.
This is why even partial knee meniscectomies are
linked to early osteoarthritis.   Symptoms When
you injure your meniscus, it usually takes 24
hours for your knee to swell and become painful.
The following are common signs and symptoms of a
torn meniscus Swelling and stiffness A
popping sensation Pain, especially when
twisting or rotating your knee Inability to
fully squat on the involved leg Difficulty
straightening your knee fully Feeling as though
your knee is locked in place when you try to move
it Feeling of your knee giving way
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Conservative treatment  The body has a miraculous
way of healing itself. The role of your clinician
is to educate each patient on the best movements
and activities that enhance healing. The goal is
to fully recover from a knee injury as fast as
possible, return to our sport and full activity
and prevent future arthritis. Knee Treatment for
the inflammatory stage  RICE  (rest, ice,
compression, elevation) During the
acute/inflammatory stage of healing, RICE (Rest,
Ice, Compression, Elevation) is the treatment
protocol. Rest depends on the severity of the
injury. Fractures and significant inflammation
would require complete rest. But most knee
injuries require active rest or continuing with
light activity within tolerance to prevent muscle
wasting and poor healing of tendons. Derangement
A problem within the joint secondary to a
meniscal tear Joints have cartilage protecting
the outer layer of bone and an extra buffer
between the bones. In the knee, this cushion is
known as the meniscus. Repetitive motion
strains the joint, especially if the movement is
awkward or has poor mechanics.
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This strain can cause microscopic tears in the
cartilage and even cause a tiny piece of your
cartilage to break off. This is part of the
natural wear and tear process, but excessive
activity combined with poor mechanics will
advance this breakdown, known as a derangement.
Even though this broken piece is tiny, it can
cause pain and loss of motion if it interferes
with the joints smooth mobility. Derangements
are characterized by intermittent pain, pain
during movement, and a loss of motion (can be
constant pain if a joint is held in an abnormal
position, such as a dislocation). Knee Treatment
for Derangements  Reduction of derangement,
Regain full range of motion, Progress to the
recovery of function. Research Partial Knee
Meniscectomies Linked to Early Osteoarthritis A r
ecent randomized controlled study just published
a few months ago compared partial meniscectomies
in young patients (aged 18-45 years) to physical
therapy and the option to delay surgery. Most
studies prior were not randomly controlled. At 24
months, there was no difference between physical
therapy and arthroscopic partial meniscectomy.
59 of randomized patients to PT did not undergo
delayed arthroscopic surgery. They concluded that
physical therapy should be an alternative to
early arthroscopic surgery.
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Another study out just this month tracked the
prevalence of osteoarthritis between 5 and 15
years after arthroscopic partial meniscectomy.
Arthritis was found in 23-100 across all periods
with increased rates between 10-15 years. They
also found that the uninjured knee had a higher
rate of osteoarthritis and theorized that
arthroscopic surgery might lead to bilateral
maladaptive movement patterns, potentially
affecting the uninjured knee. Additional studies
questioning the value and frequency of
arthroscopic partial meniscectomies in favor of
conservative care 2020 Sihvonen et al.
(BJSM) Five-year follow-up found that
arthroscopic partial meniscectomy was not
superior to placebo surgery, and there is a 13
increased risk of progression of knee
osteoarthritis. 2019 Katz et al (Arthritis
Rheum) Five-year outcome of operative and
nonoperative management of meniscal tear in
persons older than forty-five years Pain
improved in both groups with no significant
difference, but the operative group had a greater
frequency of total knee replacement surgery.
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2017 Beaufils Pujol. Elsevier A literature
review concluded that a paradigm shift is needed
in favor of meniscal preservation. Meniscectomy
should no longer be the first-line option. 2016
Kise et al. (BMJ) Exercise therapy versus
arthroscopic partial meniscectomy for
degenerative meniscal tear in middle-aged
patients a randomized controlled trial with
two-year follow-up. No difference was found, and
the PT group showed greater quadriceps
strength. 2015 Hulet et al (Knee Surg Sports
TraumatolArthrosc) At 20 years follow-up, 56
osteoarthritis was found following lateral
meniscectomy.  2013 Sihvonen et al. (N Engl J
Med) 146 patients with a degenerative meniscus
tear and no evidence of OA were randomized into
arthroscopic partial meniscectomy or a sham
surgery group. The outcomes after arthroscopic
partial meniscectomy were no better than those
that underwent a sham surgical procedure.
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1998 Charrois, Ayral Beaufils (Revue de
Chirurgie Orthopedique et Reparatrice de
Lappareil Moteur) The authors noted that
osteoarthritis is common following meniscectomy.
In a multicenter study by the French Arthroscopy
Society, joint line narrowing was 22 in the
medial meniscus and 40 in the lateral meniscus
at a mean of 13 years follow-up.  1995 Rangger,
Klestil Gloetzer AJSM  Partial medial or
lateral meniscectomy leads to a significant
increase in osteoarthritic changes, even when
performed arthroscopically. (Badlani et al.,
2013 Chang and Brophy, 2020 Rai et al., 2020
Adams et al., 2021 Bedrin et al., 2021).  The
moral is dont rush in to have surgery. Give your
body a chance to do what it knows best heal.
Your bodys ability to heal is miraculous and way
ahead of our current technological ability. Seek
medical treatment based on conservative care that
empowers healing, educating you on the best
practices to enhance your bodys ability to heal
itself. If after you have exhausted conservative
care, only then should you consider surgery. But
remember partial knee meniscectomies are linked
to early osteoarthritis.
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